Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
www.mass.gov/masshealth
MassHealth
All Provider Bulletin 240
December 2013
TO: All Providers Participating in MassHealth
FROM: Kristin L. Thorn, Medicaid Director
RE: Temporary Coverage for Applicants for Subsidized Health Insurance
Background
Since October 1, 2013, the Massachusetts Health Connector and
MassHealth have been accepting applications for subsidized health
insurance coverage effective January 1, 2014. Applicants have submitted
their information through MAhealthconnector.org, the new online,
integrated eligibility system for the Health Connector and MassHealth, as
well as through the new paper application for 2014 health care coverage.
While we are experiencing some delays in processing applications
through our new systems, our highest priority is to ensure that everyone
seeking insurance coverage has access to coverage without gaps or
delay. Many who applied are already enrolled in Commonwealth Care,
the Medical Security Program, or MassHealth and can retain their current
coverage through at least March 31, 2014. Other applicants are not
currently enrolled in any subsidized health program and need access to
health care coverage starting on January 1. The Health Connector and
MassHealth are working to process applications for subsidized coverage
as soon as possible and prioritizing those who are not currently enrolled
in any subsidized health program.
Starting January 1, 2014, individuals not currently enrolled in any
subsidized health program who have applied for subsidized coverage,
and whose applications we have not been able to process, will have
access to temporary coverage until we are able to process their
applications and make final eligibility determinations. Individuals enrolled
in this temporary coverage will receive a fee-for-service benefit through
MassHealth. Providers who provide MassHealth-covered services to
these individuals and submit claims directly to MassHealth will receive
payment from MassHealth as they would for any MassHealth member.
Proof of Eligibility
Applicants as described above may be enrolled in this temporary
coverage beginning January 1, 2014, until their applications are
processed and an eligibility determination is made.
Continued on next page
MassHealth
All Provider Bulletin 240
December 2013
Page 2
Proof of Eligibility
(cont.)
Individuals enrolled in this coverage will receive a letter from MassHealth
and the Massachusetts Health Connector informing them of their
temporary coverage. A sample letter is attached to this bulletin. The first
of these letters will be sent out during the last week of December 2013.
This letter will contain the individual’s temporary member ID and will
serve as the individual’s temporary ID card. These individuals will not
receive a MassHealth or other health insurance ID card. Individuals with
temporary coverage should present their letter to you as proof of
coverage. Providers must confirm coverage through the Eligibility
Verification System (EVS) to ensure MassHealth payment for services
provided.
Individuals will receive another letter from MassHealth and the Health
Connector with their eligibility determination once their application has
been processed. The temporary coverage will end after the eligibility
determination has been made, and EVS will be updated to reflect the
individual’s new eligibility status.
What Services Are Covered?
Any service that is covered for MassHealth Standard members is covered
for individuals receiving this temporary coverage. The same medical
necessity and prior-authorization requirements that apply to services
provided to MassHealth Standard members apply to these individuals.
Provider Responsibilities and Payment
MassHealth providers who provide services to individuals enrolled in this
temporary coverage and submit claims to MassHealth will receive
payment subject to all applicable program and administrative and billing
requirements. Providers must provide medically necessary covered
services for these individuals as they would for any MassHealth Standard
member. Providers must check EVS to confirm eligibility every time they
provide services to these individuals. As always, providers must check
EVS daily for members in inpatient settings. In EVS, eligibility for these
individuals will display as MassHealth Standard. EVS will not display any
Primary Care Clinician (PCC) Plan or managed care organization (MCO)
enrollment for these individuals as they are not eligible to enroll in
managed care.
Questions
If you have any questions about the information in this bulletin, please
contact MassHealth Customer Service at 1-800-841-2900, e-mail your
inquiry to providersupport@mahealth.net, or fax your inquiry to
617-988-8974.
MassHealth
Commonwealth of Massachusetts
Executive Office of Health and Human Services
Massachusetts Health Connector
the right place for the right plan
You can get this
information in large
print and Braille.
Call 1-800-841-2900 from
Monday through Friday,
8:00 a.m. to 5:00 p.m.
(TTY: 1-800-497-4648 for
people who are deaf, hard
of hearing, or speech
disabled).
[MAIL-TO-NAME]
[MAILING-STREET-ADDR]
[MAILING-CITY-NAME], [STATE] [ZIP-CODE]
You applied for new health insurance coverage with a start date of January 1, 2014, through the MAhealthconnector.org website or a paper application. We are still processing your application to determine if you qualify for a Health Connector plan or for MassHealth.
As of January 1, 2014, you will automatically be enrolled in temporary health insurance coverage until we make a final decision on your application.
You can use this letter as proof of coverage when you go to get health care services—the same way that you would use a health insurance card. Bring this letter with you and show it when you go to a health care provider, including a doctor, hospital, or pharmacy.
Your temporary Member ID number is: [Medicaid ID]
Here is what you need to know about your temporary health insurance coverage:
You do not need to take any action or pay any money to get this temporary coverage.
You will be enrolled automatically for coverage that starts January 1, 2014.
Your temporary benefits will cover a wide range of health care services. Read the attached Summary of Benefits for a list of covered services.
You can get covered health care services from providers that participate in the MassHealth program.
You will get a letter when we finish processing your application letting you know if you qualify for a health insurance plan through the Health Connector or through MassHealth.
Once we have processed your application and made a decision about your eligibility, your temporary benefits will end.
TC (12/13) Please turn page over
When you go to get health care services
Your temporary benefits will cover a wide range of health care services, including doctor and clinic visits, hospital stays, prescription medicines, mental health, family planning, and laboratory services. Read the attached Summary of Benefits for a list of covered services.
MassHealth has an extensive network of participating providers including all of the hospitals in Massachusetts, thousands of physicians who provide primary care and specialty services, and a statewide network of pharmacies.
When you go to get health care services while you have this temporary coverage, you should find out first whether the provider is in the MassHealth network. Find out if a provider is in the MassHealth network by either:
• contacting the provider (such as a doctor or hospital) and asking if they accept MassHealth; or
• calling MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people who are deaf, hard of hearing, or speech disabled). They can help you find a provider near you.
There may be a co-pay for prescriptions. The co-pay for most medications is $3.65. Some generic medications have a co-pay of $1.00. If you are pregnant or under age 21 you do not have to pay any co-pays. Other exceptions may apply. Check with your pharmacy or call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people who are deaf, hard of hearing, or speech disabled) for more information.
Questions?
If you have questions or need more information please call 1-855-MA-4-HLTH (855-624-4584). You can also visit MAhealthconnector.org for more information.
We apologize for the delay in processing your application. Please know that we are working hard to process your application and determine your eligibility so that if you qualify, you can enroll in a new plan. You will be covered through these temporary health insurance benefits until that process is complete.
Thank you,
MassHealth and Massachusetts Health Connector
Summary of Benefits for Temporary Coverage
This is a summary of covered services and benefits for individuals receiving temporary coverage while their applications for health insurance coverage through the Health Connector or MassHealth are processed. Please keep in mind that this summary is for your general information only. Your temporary coverage will pay for medically necessary services. Some services have limits, and some services may require prior authorization. For more information, call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people who are deaf, hard of hearing, or speech disabled).
Medical Services
Abortion Services
Acute Inpatient Hospital Services
Ambulatory Surgery Services
Audiologist Services
Chiropractor Services
Chronic Disease and Rehabilitation Inpatient Hospital Services
Community Health Center Services
Dental Services
Dialysis Services
Durable Medical Equipment
Eyeglasses, Contact Lenses, and Other Visual Aids
Family Planning Services
Hearing Aid Services
Home Health Services
Hospice Services
Laboratory Services
Long Term Services and Supports
Medical/Surgical Supplies
Orthotic Services
Outpatient Hospital Services
Oxygen and Respiratory Therapy Equipment
Pharmacy Services
Physician, Nurse Practitioner, and Nurse Midwife Services
Podiatrist Services
Prosthetic Services
Radiology and Diagnostic Services
Therapy Services (physical therapy, occupational therapy, and speech/language therapy)
Transportation Services (emergency; nonemergency transportation to medical appointments)
Vision Care (including comprehensive eye exams and vision training)
Wigs
Behavioral Health (Mental Health and Substance Use Disorder) Services
Emergency Services Program (ESP) Services
Inpatient Services
Outpatient Services
1 For individuals age 21 and over, the first 20 days of an inpatient hospital admission are covered. This limitation does not apply to inpatient stays provided in a Department of Mental Health (DMH)-licensed acute psychiatric unit within a Department of Public Health (DPH)-licensed acute hospital or in a rehabilitation unit within a DPH-licensed acute hospital.
2 Individuals age 21 and over are only eligible for emergency and certain preventive dental services.